Part 4 of 4
Wednesday, December 19, 2001

Inmates pay price for others' inattention Medical care improves only when outsiders get involved, former prison lawyer says.

Inmates pay price for others' inattention
Medical care improves only when outsiders get involved, former prison lawyer says

By Mike Ward and Bill Bishop
American-Statesman Staff
Wednesday, December 19, 2001

Last of four parts

HUNTSVILLE Gary Johnson heads the Texas prison system. He's not a doctor, so he says it is "hard for me to judge" the quality of medical care offered to inmates. "My sense as a layman is that the quality of care in the system is much higher now than it was several years ago," he said. Allen Hightower directs the agency in charge of health care in Texas prisons. It's a system he helped design when he represented Huntsville in the state Legislature.

"Should I know more about quality of care?" Hightower asked. "Maybe. I don't know. I've never really sat down and thought about it. It's not something I think about. I have confidence that the universities are thinking about that."

The question for Johnson and for Hightower, for legislators, for anyone concerned about justice in Texas, is this: How would they know about the care? How do they know that it's best to trust doctors, that the quality of care in Texas prisons is improving, that the universities are concerned first with delivering decent medicine to the state's 134,000 inmates?

In 1993, the Texas Legislature turned the care of convicts over to two universities. The University of Texas Medical Branch treats 80 percent of the inmates in 71 prison clinics and its Galveston hospital. Texas Tech University in Lubbock takes care of the remaining inmates, using prison clinics and community hospitals to provide care in West Texas.

It is a $297 million-a-year business that runs largely without outside interference, review or accounting. When challenged, it rolls up like a pill bug and turns in on itself.

What Texans don't know what, as Hightower might put it, few in state government have really sat down and thought about is whether inmates are suffering from poor, inadequate or uncaring medicine. Sometimes the Legislature, the public, the prison system, the universities don't know because they don't ask. Sometimes, the system or the state or the universities know, but it's against the law for them to tell.

The state doesn't ask for bids for medical services. (The state House of Representatives removed that requirement in 1993.) So there is no way to know the true market value of the services.

The Legislature in 1999 prohibited the Texas Department of Criminal Justice Gary Johnson's agency from monitoring the quality of medical care in the state prisons it operates. The universities have the responsibility of checking on the care they deliver. So there is never a meaningful independent review of the quality of care.

The universities have guaranteed seats on the committee that hires them to provide the care. Until last year, the two universities controlled four of six positions. Now they hold four of nine. (The prison system has two seats and three are now filled by people appointed by the governor.)

Most measures of health-care quality in prisons are secret, according to state law and rulings by state Attorney General John Cornyn. Databases of inmates' medical grievances, findings of doctors who review the deaths of inmates, inspection reports of dialysis facilities, correspondence among prison health-care administrators and inspections of prison health-care facilities are all private in Texas.

There is a different way.

Florida created the Correctional Medical Authority to oversee the quality of health care in the state's prisons. The authority is independent of the departments that operate the prisons and provide health care. The authority inspects the prisons and reviews the medical charts of prisoners who died or are receiving care for chronic conditions. The authority can, and does, issue citations if its doctors see violations of state regulations.

The authority publishes its findings. All of Florida knows, or could know, for example, that of the 57 deaths reviewed in 2000, 15 of the prisoner patients received inadequate care. The authority names the prison units where this poor care was given. It describes the inmate who died of untreated pneumonia. It tells of the inmate who should have been given a heart bypass operation. It documents the 10-month delay between a Pap smear that indicated uterine cancer and a hysterectomy, a delay that "likely contributed to the death" of the inmate.

Recently, the authority found that Florida prison psychiatrists had taken a large number of inmates off medications, said Mike Traugott, a CMA supervisor. "Inmates were decompensating (getting sicker) across the board, ending up in confinement and such," Traugott said. The authority issued a citation. The department corrected the problem.

Florida's Correctional Medical Authority doesn't guarantee flawless medical care. The authority's own reports prove that. But the CMA does provide a check, a benchmark, an independent measure of care that is missing in Texas and most other states. In Texas, after all, the agency running the prisons is barred from monitoring the care given its prisoners.

"England has Her Majesty's Inspectorate of Prisons, an auditor," said Mike Vaughn, who teaches criminal justice at Georgia State University in Atlanta. "We could really use something like that here (in the United States), somebody who is independent from the prison hierarchy and can candidly discuss problems that are occurring. We don't have anything like that now. Now, if there are problems, they just fester.

"It's tough working in prison health care," Vaughn continued. "It's not easy. And the more you look, the more depressing it gets."

First, however, you have to look.

When he testified in the federal David Ruiz case in 1999, Dr. David Smith, the head of the Texas Tech University Health Sciences Center, was also chairman of Texas' Correctional Managed Health Care Committee, the group that hires UTMB and Texas Tech.

As the head of the committee, Smith oversaw the multimillion dollar-a-year business of providing health care in Texas prisons. As an administrator at Texas Tech, Smith also provided the care to prisons in West Texas. Neither of these jobs, however, involved spending much time in prisons. Donna Brorby, the inmates' attorney in the Ruiz case, questioned Smith: Brorby: Dr. Smith, how many hours in your life have you spent in any kind of prison?
Smith: Probably less than 30.
Brorby: How many of those hours have been spent . . . at (a Texas Department of Criminal Justice) prison?
Smith: An estimate would be probably, at most, eight to 10.
Brorby: How many TDCJ prisoners have you interviewed concerning their experience of the TDCJ health-care system?
Smith: Informally, one or two at the most.
Brorby: And how many minutes or hours have you spent in those conversations with those one or two prisoners?
Smith: Less than an hour.

The testimony goes on from there. Smith had spent less than 10 hours talking with medical staff who worked at prison units. He couldn't name one of them. He said he had looked at "only a couple" medical charts of prisoners, but he could "not precisely" remember the last time he had done so. Health care in Texas prisons has improved over the years. Always, however, the improvements have come after an outside agency or court questioned what was happening inside the walls, after someone interrupted the way the system worked. After somebody made the decision to look.

"Back in the '70s, medical care in the prison system was almost nonexistent," Allen Hightower recalled. "Inmates doctored on each other. They did operations on each other. They set broken legs on each other without painkillers. If you were in prison back then, you just prayed you didn't get sick.

"The only thing that changed," Hightower said, "was that the federal court got on us and made us change. The talk on the street certainly didn't push us to change."

That is how things have worked in Texas. An investigative commission in 1909 found evidence of "atrocious and brutal treatment" in the prisons, leading the state to end the practice of leasing out convicts to work in private businesses.

After 100 legislators and Gov. Dan Moody visited Texas prisons in 1930, finding conditions "not fit for a dog," the state built a new hospital for inmates and began education programs.

The Texas State Council of Methodist Women took up the cause of "humane, sane and Christian" prisons in 1947, and the state responded by beginning a school for prison guards and changing the system's leadership.

Prisoners began legal actions against the prisons in the 1960s, and in 1980 a federal district judge ruled in favor of Ruiz, finding the treatment of convicts in the Texas prison system to be unconstitutional. In particular, the judge found that the medical care described by Hightower constituted cruel and unusual punishment.

The prison system hired doctors and made sure inmates had access to care. "In the old days the problem was getting people to a doctor at all," said Brorby, Ruiz's lawyer. "They do have some system in place. They didn't use to, and they do now. It's no mean feat."

Hightower said the Legislature turned health care over to the universities partially to placate the federal court. The plan worked. Although U.S. District Judge William Wayne Justice found evidence in 1999 of "significant, even deadly, inadequacies in the level of care provided to ill inmates," he ruled this year that the state was no longer violating federal law. A state auditor's report in 1998 chastised Smith's committee and the Legislature for setting up a system in which two universities essentially hired themselves to provide a service. The auditor noted that the service was provided without sufficient outside monitoring.

Since the auditor's report there have been some reforms. In 1999, the Legislature added three gubernatorial appointees to the committee. The universities agreed to pay financial penalties if they delivered poor-quality medical care.

The committee and the universities signed a new contract in September that "addresses the quality of care issue," said Gary Johnson, executive director of the Texas Department of Criminal Justice. "We have that nailed down."

The new contract requires the universities to answer inmate grievances within 45 days. Earlier this year, some legislators had chastised the two schools for being slow in responding to requests for information.

Otherwise, the new contract changes little from the "performance monitoring" section found in the old contract. As before, the universities "shall be used to the greatest extent feasible for clinical oversight of quality-of-care issues."

University doctors still review the work of university doctors in peer reviews of medical care in the prisons. (A prison system doctor is an ad hoc member of these committees.) "We do a lot of peer review," said Dr. Ben G. Raimer, a UTMB vice president. "So far peer review has occurred here and at the units, and under a new system, there will be more interaction between the staff at this hospital (in Galveston) and the units."

"I won't know whether a doctor was fired or not, or whether someone decided that someone wasn't given the right medicine or treatment," Hightower said. "The universities handle that themselves."

The contract also requires each prison to pass inspections by either the National Commission on Correctional Health Care or the American Correctional Association. The state's prison health-care committee is ending its contracts with the NCCHC, an organization begun by the American Medical Association. ACA, an organization begun by wardens, will take over.

Although these inspections were required by the federal courts in the Ruiz case, Brorby said the inmates never requested that the prisons be accredited. "We never cared about accreditation," Brorby said recently, "because we never thought the NCCHC measured quality of care."

Don Bennett is executive director of the Correctional Medical Authority in Florida. He said the NCCHC does a "good inspection."

"They look to see if the systems are there and the policies are in place," he said. "My analogy is, they make sure you have a car and that the car has four wheels and seats. But you don't know how the car will run." The ACA inspections are even more limited, Bennett said. "ACA has developed some new audit instruments that are much better," he said. "But we (in Florida) go in with six to eight people, including physicians, psychiatrists, psychologists, nurses and other medical professionals and spend three days. ACA goes for one or two days with two or three nurses. "In my opinion, NCCHC and ACA are not sufficient to measure true quality of prison health care," he said. "They are very good at ensuring that systems are operating. But if you are checking for quality, more resources would have to be provided."

How likely is that?

"Texans, by and large, have always been really interested in getting their criminals off the street, and then they just want to forget about them," said Hightower, who spent 14 years as a Democratic state representative. "The access to health care we are providing is better than what my mama gets." At a dedication of a new prison health-care facility in early December, Rep. Patricia Gray, a Galveston Democrat, said there was "no quarrel with the fact we have to deliver health care in prisons, but there are a lot of people who think it should be an 18th century London dungeon."

Prisoners in the system, the federal judge in the Ruiz case, the doctors who studied the system in that case and the state auditor have looked within the walls, and this is what they all, to varying degrees, have seen: Care can be excellent at UTMB's prison hospital in Galveston and at many of the West Texas prisons served by Texas Tech. Care in the prisons themselves can be abysmal.

Nobody says providing medical care to 134,000 inmates is an easy business. Inmates are sicker than people in the free world. Actuaries figure that the average 30-year-old prisoner has the health problems of a 40-year old. About one in every seven is mentally unstable. Some convicts tell lies. Some malinger. Others are dangerous. An ill convict raped two nurses in January at a hospital in Lubbock.

Inmates practically repel sympathy.

Therefore, they demand attention.

"TDCJ has never been open," said Steve Martin, a prison consultant in Austin and the former general counsel for the Texas prison system. "They have been the opposite. The feeling is that if they open anything up, they'll have problems. And that goes back years and years.

"Very few, if any, major initiatives or changes have been incorporated by the agency of its own initiative. Up to now it's been because of external pressure the courts, the Legislature, public reaction. It's always been that way."

You may contact Mike Ward at mward@statesman.com or (512) 445-1712 and Bill Bishop at bbishop@statesman.com or (512) 445-3634.

The Ex-Convicts In their own words.

The Ex-Convicts

In their own words Wednesday, December 19, 2001

'We have a bunch of little programs to check health care (in the prisons), but it's not being done. My suggestion is, we have to have a governing body that will look and say, "This is not healthy." They have money enough to take care of everyone who needs it.'

Lester Allen, 31, left prison this year after serving 10 years for robbery. In prison, Allen worked with dying and sick prisoners. He's now working in Houston with a decorating company and is establishing a nonprofit group in which teen-agers would counsel their peers about the dangers of HIV.

'How can health care in prison be improved? That's a good question. They must have some way of making these people more accountable. You need to set up some outside agency that has no interest either way. It would make the staff think twice about the kind of care they pass out.'

Cadarell Freeman, 37, left prison in September 2000 after serving 11 years for passing bad checks. Freeman claims poor health care in Texas prisons put him in a wheelchair. In the past year, Freeman regained his strength and took a job at a tire store in southeast Houston. Freeman depends on Medicaid to pay for his prescriptions, which run $3,000 a month. Because people who earn more than a certain amount are not eligible for Medicaid, he has had to cut back his work hours to two days a week.

'At UTMB prisons, there was no care. You can't get in to see the doctor. At Texas Tech, I got perfect medical care. I had two doctors and six nurses crawling all over me. I thought I was being mugged. . . . When Texas Tech started (in the prisons), they started from scratch, so they had a chance. UTMB took over a system that was already corrupt, busted and confused.'

Kenneth Malone, 39, left prison in January after serving seven years for kidnapping. Malone, who has diabetes, claims poor health care in prison caused him to lose his eyesight. From his parents' home in Amarillo, Malone is waging a one-man legal campaign against the prison system.

The Administrators Official response.

The administrators

Official response Wednesday, December 19, 2001

'Part of the problem in the past has been that the Correctional Managed Health Care Committee is not under the control of (the Texas Department of Criminal Justice). We don't have a big stick to make them do what we say. . . . That is no longer an issue. We have resolved the issues. Our working relationship is very good. I think the quality of care for inmates is there. I think it's always been there. I think they're doing a fine job. They're the docs. They know medicine; we don't. They know their side of this. That's the way it's supposed to work.'

A.M. 'Mac' Stringfellow, chairman of the Texas Board of Criminal Justice 'Bureaucracies typically don't show much initiative themselves. That's rocking the boat, and bureaucracies tend not to embrace boat-rockers. The corrections business can be even more that way. There are a few states that self-examine, but they are unusual in that respect: Washington, Oregon, Minnesota. The corrections systems there always look to improve. They boat-rock themselves. . . . Once attorneys in the Ruiz case started opening things up and asking questions, bad things happened. And there are a lot of people in the system who believe bad things have been happening ever since. Their role models were the administrators who thought they don't have to answer to anyone. I'm sure they see openness as a threat to their power.'

Steve Martin, prison consultant and former general counsel of the Texas prison system

'As with any large system, you can find some problems. But they have not been malicious, and not because people did not care. Do bad things happen in health care? Yes. They sometimes do. Does that mean the whole system is bad? No. There have been some bumps along the way, but we have an excellent system that is continuing to improve.'

Dr. Ben G. Raimer, a vice president of the University of Texas Medical Branch at Galveston

'I can say without a doubt in dealing with the universities and the others in this: There is a desire to provide access to proper care. The health care inmates get now is a thousand times better than what they were getting 20 years ago. It's a different world than it was. . . . In places like Dumas and Anahuac and other rural areas of Texas, inmates have much better access to care than the good citizens of those parts of Texas do.'

Allen Hightower, executive director of the state's Correctional Managed Health Care Committee and a former state representative

'I don't agree that the managed-care system we have lacks oversight. TDCJ has representatives on the committee, and we are not bashful about making our opinions known about care, and about picking up the telephone and calling UTMB and Texas Tech and asking questions or raising issues we think are important.'

Gary Johnson, executive director of the Texas Department of Criminal Justice 'I believe the current health-care program provides the access to care and quality of care required constitutionally. . . . Texas is a leader in correctional managed health care.'

Dr. Lannette Linthicum, health services director, Texas Department of Criminal Justice

Editorial Legislature must fix prison health care.

EDITORIAL

Legislature must fix prison health care Austin American-Statesman Wednesday, December 19, 2001

If you prefer to see the metaphorical glass half full rather than half empty, you may focus on how far prison medical care has come in Texas. "Back in the '70s, medical care in the prison system was almost non-existent," says Allen Hightower, a Texan who recalls it in vivid detail. The former legislator now directs the state agency in charge of prison medical care. "Inmates doctored on each other. They did operations on each other. They set broken legs on each other without painkillers. If you were in prison back then, you just prayed you didn't get sick."

With or without prayer, a lot of the inmates in Texas prison units get sick. Many come to state custody with multiple health problems. Others stay around long enough to see their health fail. In the vast prison system, where the population tripled in the past decade, drug-resistant infections are a plague. An estimated 15 percent of the prisoners suffer mental illness. Alcoholism and similar addictions are epidemic.

And as the average age of the state's prisoners rises inexorably a function of free-world demographics and long, tough-on-crime sentences the bodily failures of advanced age create intractable problems. Prisoners need dialysis, surgery, wheelchairs, insulin. They need to be turned to prevent bedsores. Some need daily psychiatric medication. Some can barely see.

In recent decades, prison medical care improved because a few determined people fought against inhumane conditions. Doggedly bucking official resistance, public indifference and ridicule of their goals, they forced a spotlight into some dark places. Finally, the federal courts told Texas lawmakers to shape up. They said constitutional rights were being abused.

"The only thing that changed was that the federal court got on us and made us change. The talk on the street certainly didn't push us to change," Hightower told reporters Mike Ward and Bill Bishop. The reporters' four-day series "Sick in Secret: The hidden world of prison health care" concludes today.

The series shows that while prison medical care has improved enough to meet minimum state requirements, serious deficiencies continue. And if for no other reason than that many prisoners return to live among us, their health is our concern.

At least the state needs to make the prison medical system less secret. This is a public system, paid for by taxpayers and affecting public health. A system created by the State of Florida, allowing citizens to know with some precision how their money is spent on treatment, could be a model.

Texas legislators should repeal a law they unwisely enacted in 1999 that prohibits prison system officials from monitoring prison medical care.

The two medical schools that provide the care under contract the University of Texas Medical Branch at Galveston and Texas Tech University in Lubbock in effect monitor themselves. That's a formula for trouble.

A legislative committee charged with studying prison medical care should put repeal of this ill-conceived law at the top of its agenda. House Speaker Pete Laney already has instructed the House Corrections Committee to "study the delivery of health care within the Texas prison system, including the number and types of health care practitioners needed, the recruitment and retention of those practitioners, management of chronic diseases, and the use of telemedicine and other technologies."

The committee should use that directive, and the findings in the American-Statesman series, to launch a tough, high-profile investigation. By the time the Legislature convenes in January 2003, the committee and its Senate counterpart should have arrived at hard recommendations for reform. More transparency and increased oversight should be the goals. In the meantime, prison officials should act.

The devil is indeed in details. For instance, an obscure subsection of the health code closes to public inspection the reports of state inspections of kidney dialysis facilities. Ward and Bishop found evidence that some prisoners in need of these life-saving facilities for cleansing blood were treated amid conditions verging on the primitive.

Citizens should take an interest in the state prisons in their communities, which make up one of the largest prison systems in the world. Texas imprisons a greater percentage of its population than almost any other state. And despite a rising prison death toll from disease, homicide, suicide and execution by the state thousands of prisoners return to our communities each year.

If they're more violent, less able to work and sicker than when we sent them away, those communities will suffer.

More coverage

10/12/02: UT calls for independent review of prison medical care it provides

UT calls for independent review of prison medical care it provides MORE ON THIS STORY

SICK IN SECRET

The hidden world of prison health care

'Deadly inadequacies' plague inmate wards Gaps in evaluating care let some mistakes go unnoticed.

Becoming guinea pigs to avoid poor prison care Ill inmates urge each other to join experiments.

State puts lockdown on the truth Texas laws and those who rule on them keep records of poor prison medicine out of public view.

Inmates pay price for others' inattention Medical care improves only when outsiders get involved, former prison lawyer says.

The rest of the series

________________________________________

By Mike Ward and Bill Bishop AMERICAN-STATESMAN STAFF Saturday, October 12, 2002

University of Texas officials, concerned about criticism of the prison health-care system they operate, unveiled plans Friday for an independent evaluation of the care given by the staff of their medical branch. UT System Chancellor Mark Yudof said the review -- the first top-to-bottom outside scrutiny of prison medical care in Texas in years -- will be conducted by a three-member panel named by Texas Health Department Commissioner Eduardo Sanchez.

Convicts, their families and advocacy groups have complained about inadequate and improper care, even lack of care. In December, the Austin American-Statesman detailed continuing problems and issues with medical care in Texas prisons. With the recent end of federal court monitoring of prison conditions in Texas, inmates' families, advocates and prisoners themselves have expressed concern that the quality of medical care is declining. Prison officials and medical-care providers have insisted that the complaints are mostly overblown or unfounded. In the past,

Under a contract with the prison system, the University of Texas Medical Branch at Galveston -- a part of the UT System -- provides medical care to roughly 80 percent of Texas' 140,000 imprisoned criminals, most of it in the prisons in the eastern two-thirds of the state. Texas Tech University provides medical care in the rest of the prisons. The state spends more than $297 million a year to provide health care in prisons.

Although the review will involve only the prison clinics operated by UT Medical Branch, Yudof said the results will be made public and will be shared with Texas Tech officials.

In a letter Wednesday to Sanchez, Yudof said he wants the evaluation team to "review the quality of healthcare in TDCJ by whatever means is most appropriate, taking into account the special environment in which medical care must be rendered."

Once the review is done, the team will provide "recommendations regarding any deficiencies" and "recommendations regarding future and on-going assessments of quality care." Written reports are to be provided to Sanchez, Yudof and Dr. John Stobo, president of UT Medical Branch. Saying he wants to make sure Texas prisoners receive proper health care, Yudof said Friday that the review "is the right thing to do." He said the reports in the American-Statesman worried him, and he made the review a priority soon after becoming chancellor in September. Months ago, UT System officials did their own review and said they found no problem.

"We need to have people who are independent look at it," Yudof said. "We need to know if we have the right oversight system." Yudof said he would like the review to be finished by the end of the year. Convicts' families and advocates overwhelmingly supported the announcement Friday.

"That's incredible -- really good news," said Yolanda Torres, a lawyer who has been involved in monitoring prison health-care issues. "This is a very serious issue that needs independent attention."

"From the cases we've reviewed where there has been heavy over-drugging, neglect in cages and many other problems, any outside oversight such as this will be good," said Jerry Boswell, president of the Citizens Commission on Human Rights, an Austin-based group that investigates accusations of institutional malpractice. "I've never heard of Texas doing an outside review like this, so that's a welcome change."

Prison officials in Austin and Huntsville said they were unfamiliar with Yudof's proposal and could not immediately comment.

Stobo said the review "seems like a very reasonable thing to do." He said that although a number of recent changes in the prison health-care system have "much improved" the quality of care, the review could spur other positive changes.

In his letter, Yudof expressed his intention that no committee members "will have any ties" to the UT System, the UT Medical Branch or the Department of Criminal Justice. The UT System will provide a list of potential candidates to Sanchez, Yudof said, but "the commissioner is free to select any members he chooses."

Two of the three panelists will be physicians, Yudof said. Doug McBride, a spokesman for the Health Department, said Friday that Sanchez is "nowhere close to appointing this team. This process is just beginning. We haven't even received the letter yet." In his letter, Yudof told Sanchez that the UT System will pick up the tab for the study. He and Stobo said they have no idea what it might cost. Yudof said he expects the team will spend time reviewing convicts' case files, conducting on-site inspections and reviewing the systems and methods that other states use to ensure that prison health care is adequate and proper. That, some experts say, might be a tough part of the study. Inspecting prison health-care delivery is a "complex issue," said Mike Traugott, a supervisor with Florida's Correctional Medical Authority, which has been touted as a model for outside oversight. "It's more than gathering a bunch of clinicians and sending them into prisons. You need to have some structure. Ten clinicians will have 10 different opinions."

The authority is an independent agency in charge of monitoring health care provided in Florida's prisons. It inspects each prison unit every three years. Inspectors review care given in a sample of inmate cases; the authority publishes the results of these inspections.

Examining the care given to individual inmates is an essential part of the Florida system, Traugott said.

"You really have to see how things function at that level even if the oversight is centrally located," he said.

The cost in Florida to "review the quality of health care" in the state's prison system is $1.4 million a year.

Florida has 64 prison units. Texas has 112. mward@statesman.com; 445-1712

11/21/02: Choosing prison-health panel starts anew after nominee background checks

Review of prison clinics stumbles Problems with candidates for evaluating inmate care have state seeking new doctors
By Mike Ward AMERICAN-STATESMAN STAFF Thursday, November 21, 2002

Two of the seven doctors recommended to conduct an evaluation of Texas' controversial prison health clinics have had their medical licenses revoked or suspended for sexual misconduct, and another was cited this year for negligent care.

The other four candidates are either graduates of University of Texas medical schools or have professional ties to Texas prison officials or the UT System -- despite a pledge to make the study independent of any ties to the UT System, which runs most of the clinics, or to the state prison system.

An embarrassed Dr. James Guckian, the UT System's acting executive vice chancellor for health affairs who oversees prison medical programs, dropped all but one candidate from the list Wednesday after learning about the candidates' backgrounds from the Austin American-Statesman.

"We are going to start over," Guckian said. "If there is some good news here, it is that none of these people, no one, (had) been appointed." Last month, UT System Chancellor Mark Yudof asked Texas Health Commissioner Eduardo Sanchez to appoint a three-member team of experts with "laudable records in correctional health care" and without any ties to UT, the University of Texas Medical Branch in Galveston or Texas' prison system to conduct a special evaluation of prison health care. His action followed continued complaints about the quality of care from convicts, their families and advocates for prisoners. UT's Medical Branch provides health care to 80 percent of Texas' 146,000 inmates. The Texas Tech University System cares for the rest.

Yudof offered to provide a list of possible candidates for Sanchez to consider for the team. The names came from UT Medical Branch officials and from others familiar with prison medicine, Guckian said. Health Department officials said they added two names after consulting with UT.

On the UT list: Dr. Gail Williams, whose medical license has been revoked in two states for alleged sexual misconduct and other charges; and Dr. Beltran Pages, whose license was suspended for three years after a state board found he had sexually abused a female patient.

Williams, a psychiatrist, lost his first medical license in 1985 after Michigan's Board of Medicine found him guilty of having sex with a patient and fraudulently billing an insurance company for sexual encounters as therapy sessions. Michigan officials denied Williams' requests for reinstatement in 1987, 1989 and 1990.

About the time Michigan was denying the last request, Williams was licensed to practice in Oklahoma, where his practice was restricted to a supervised setting and where he could treat female patients only with a chaperone present. His job was chief of mental health services for Oklahoma's prisons. Three years later, he lost that job and his Oklahoma license after being accused of sexually battering and harassing a prison nurse and other female staffers.

In 1994, Kansas refused to issue him a license. Before year's end he was working again, this time in Alabama, with a restricted medical license. Without making mention of Williams' past troubles, UT officials noted in their list of suggested candidates for the evaluation team that Williams "served as chief psychiatrist for the Alabama Department of Corrections for the last nine years." Alabama prison officials said Williams worked for two private contract-care providers, not the state.

Williams did not return a phone call for comment Wednesday. In earlier interviews, he denied the allegations in Michigan and Oklahoma and said he did not contest the Oklahoma license revocation because he missed a filing deadline.

Pages, also a psychiatrist, had his license suspended in 1988 for three years after the Florida Board of Medicine said he had sexually abused a female patient. He denied the accusation.

The board reinstated his license in 1992, provided that he treat only men. Florida records show Pages' licensure probation and restrictions ended in 1997. In recommending Pages, UT officials noted that before he became chief of mental health services for the North Carolina Department of Correction two years ago, "he had a significant tenure with the Florida Department of Corrections overseeing mental health services." Yolanda Murphy, a spokeswoman for the Florida corrections agency, said personnel records show that Pages worked for the agency from September 1985 until July 2000, departing as a senior physician at a prison unit.

Pages did not return a phone call Wednesday. Instead, he phoned Health Department officials to allow them to respond to a reporter's questions, said Doug McBride, the department's chief spokesman.

Dr. Richard Garden, medical director at the Utah State Prison, was also recommended by UT officials. In June, Utah records show, he received a nondisciplinary public warning and admonition for alleged negligence in treating a 62-year-old convict who died of pneumonia in 1998.

In its initial allegations filed in August 2001, the Utah Department of Commerce's Division of Occupational and Professional Licensing alleged that Garden was negligent for not properly treating the patient and for failing to properly supervise two physician assistants who were working with him.

In settling the case with a public admonition to Garden, it noted that he "has been instrumental in improving the quality and delivery of health care at the Utah State Prison."

Garden did not return phone calls for comment. While admitting they did no background checks, UT and Health Department officials expressed surprise that the doctors with past licensing problems came so highly recommended.

"I would have thought, given the titles and positions of some of these people, that their backgrounds would have been reviewed by their existing and current employers," Guckian said.

The four other candidates had another potential conflict: ties to the UT System, UT Medical Branch or Texas prisons.

Dr. H. Mark Guidry, the Health Department's regional public health director in Houston, and Dr. David A. Valdez, medical director for insurance giant Aetna in San Antonio, have served for several years on the Texas Statewide Health Coordinating Council with Dr. Ben G. Raimer, head of UT Medical Branch's prison health-care program, which is to be the focus of the study.

In addition, Guidry graduated from UT Medical Branch in 1987; Valdez graduated from UT's Health Science Center in San Antonio in 1991; and a third candidate, Dr. Charles E. Bell, the Health Department's executive deputy commissioner, graduated from UT's Southwestern Medical Center in Dallas in 1983.

McBride said both Bell and Guidry withdrew from consideration several days ago -- Bell because of other commitments, and Guidry because he is resigning his Health Department post to become director of the Galveston County Health District. McBride said Sanchez added them to the list after discussions with UT officials.

The other doctor on UT's list was Dr. Steven Shelton, a nationally known correctional physician who has been medical director for the Oregon Department of Corrections for the past decade. Shelton is president-elect of the Society of Correctional Physicians. Dr. Lannette Linthicum, medical director for the Texas Department of Criminal Justice, is treasurer of the Chicago-based trade group.

Despite that professional tie to Linthicum, Guckian left Shelton as the lone remaining candidate. "There are so few (top prison doctors) over the country, and they are going to obviously know each other or serve on boards together," he said.

Yudof defended the recommended candidates as a "raw list" that he assumed would be scrutinized more closely by those who were making the selections. McBride said that, although Health Department officials didn't envision that as part of their role, "you can bet we'll be doing background checks on everyone now."

Guckian said Wednesday's chain of events will delay the evaluation's completion until late January. And though the Health Department still will appoint the team members, the private Texas Medical Foundation will manage the evaluation and the final report because it "has had some experience in peer review and review of quality of care," he said.

The foundation, an organization of licensed physicians, does peer review and quality improvement work for the Texas health-care community.

mward@statesman.com

11/22/02: Groups assail prison review process

Groups assail prison review process UT officials shouldn't be involved in picking panelists to examine inmate care, they say
By Mike Ward
AMERICAN-STATESMAN STAFF
Friday, November 22, 2002

Prison reform advocates and government watchdog groups Thursday called for University of Texas System officials to withdraw from helping to select an independent team to study the quality of the medical care UT provides in Texas prisons.

The calls came after the Austin American-Statesman discovered Wednesday that of the seven doctors UT officials had recommended, two have had their medical licenses suspended or revoked in other states, another had been cited earlier this year for negligence and the others either graduated from UT medical schools or had professional ties to UT and prison officials.

Embarrassed UT officials immediately ordered a new search.

Last month, UT System Chancellor Mark Yudof asked Texas Health Commissioner Eduardo Sanchez to appoint an evaluation team of three people with laudable records in correctional health and without ties to Texas prisons or the UT System. UT officials and the Health Department compiled the list of physicians who would conduct a special study of the state's prison clinics.

In scrapping the candidates list Wednesday, UT officials kept only one name: Steven Shelton, medical director for Oregon's prison system, even though Shelton is an officer of the Society of Correctional Physicians with Lannette Linthicum, medical director for the Texas Department of Criminal Justice.

"It stinks for the people whose work is going to be reviewed to be suggesting the candidates," said Yolanda Torres, a Huntsville-area lawyer who monitors conditions in Texas prisons. "It's ridiculous for candidates with this background to be on the list. It appears there is no intent to do a legitimate review."

Meredith Rountree, director of the American Civil Liberties Union's Prison and Jail Accountability Project, which monitors Texas prison conditions, said the involvement of UT System officials in selecting team members "does not inspire any confidence that this report will truly be independent."

"We think the (prison health-care) system has some very serious problems that demand a top-notch and independent review," she said. Yudof called for the evaluation in response tocontinued complaints from inmates, their families and advocates for prisoners about the quality of care.

The UT Medical Branch provides health care to 80 percent of Texas' 146,000 inmates. The Texas Tech University System cares for the rest. UT System administrators and Health Department officials insisted that they remain confident that the process for selecting the evaluation team can work with UT System officials involved.

"From day one, Chancellor Yudof has told Eduardo Sanchez that he was free to select anyone he wanted to -- and that we were only offering the list of candidates to help," said Michael Warden, a UT System spokesman. "We want an independent evaluation and remain ready to help in this process however we can."

Rountree and several others suggested that an independent national group such as the National Institute of Corrections, an arm of the U.S. Department of Justice, would be appropriate to do the study or assist with it. Suzy Woodford, executive director of Common Cause Texas, echoed those sentiments. She said Shelton should be dropped from the list of candidates because of his professional tie to Linthicum.

"Based on their performance so far, UT needs to back out of the selection process," she said.

"It's analogous to Enron hiring an independent auditor and then choosing which auditors do the audit. It doesn't work," echoed Tom Smith, Texas director of Public Citizen.

"I see no evidence that it is harder to find impartial experts in the prison field than in other fields," said state Rep. Terri Hodge, D-Dallas, a member of the House Corrections Committee, which oversees prison health care. Hodge has been a critic of the quality of inmate care. mward@statesman.com

11/23/02: Study of care in prisons criticized

Study of care in prisons criticized Proposal called cheaper, more limited than previous audit.
By Mike Ward
AMERICAN-STATESMAN STAFF
Saturday, November 23, 2002

A proposal to study prison health care in Texas falls short, the lawyer who oversaw a similar study in Texas four years ago says.

The Texas Health Department on Friday released a plan for how the study would be conducted. It would have a review of previous quality-of-care audits and public allegations of problems, including newspaper articles. Medical records would be reviewed, and doctors, convicts and prison officials would be interviewed "as appropriate."

The proposed study, requested by University of Texas System Chancellor Mark Yudof, would be cheaper and more limited than the study that was part of a prison reform lawsuit known as the Ruiz case and was overseen by Donna Brorby, the plaintiff's lead attorney.

"The state attacked our audit in Ruiz as insufficient to prove what systemwide quality of care was," said Brorby. "That (study) was for mental and physical health care. The state Department of Health should make it its business to do an audit that it can be proud of, not a whitewash."

Dr. James Guckian, the UT System's acting executive vice chancellor for health affairs who oversees prison medical programs, said officials expect to spend $30,000 to $40,000 for the study, which Health Department officials said will be conducted by the private Texas Medical Foundation under the Health Department's auspices.

The last independent review of prison health care, in the Ruiz case, cost more than $400,000. A team of doctors led the effort, which included examining medical records, tracking complaints and evaluating quality of care in the prison clinics.

On Friday, Brorby suggested that Texas officals "start like we did, with a death chart audit (an audit of prison deaths) or a representative sample of charts for certain basic causes of death. That piece might be able to be done for ($30,000 to $60,000)."

Doug McBride, a Health Department spokesman, said the scope of the evaluation, as outlined in a Nov. 12 letter to the Texas Medical Foundation from Dr. Charles Bell, the Health Department's executive deputy commissioner, could change. But it was drafted based on the charge proposed by Yudof last month, McBride said.

"They asked us to do this as a courtesy, and we are doing it, but we are not experts in correctional health care," McBride said. "I don't know that we envisioned this would be as big a commitment as it has become but it needs to be done, and we'll be working out the specifics."

Meredith Rountree, director of the American Civil Liberties Union's Prison and Jail Accountability Project, called the outline of the proposed study "very disappointing." Her group monitors Texas prison conditions.

"This is such an opportunity, and it appears they are going to repeat the same superficial studies that have rubber-stamped a system that has problems that aren't being addressed or corrected," she said.

Last month, Yudof asked Texas Health Commissioner Eduardo Sanchez to appoint a three-member team to evaluate prison clinics operated by the University of Texas Medical Branch at Galveston. The UT Medical Branch provides care to about 80 percent of Texas' 146,000 prisoners; Texas Tech University provides the rest.

On Wednesday, officials started looking for new candidates after the Austin American-Statesman disclosed details about the backgrounds of the seven candidates recommended by UT System officials. Two had had their licenses revoked or suspended in other states for sexual misconduct. One had been cited for negligence. The others had graduated from UT medical schools or had professional ties to the UT Medical Branch and prison officials. Yudof earlier had asked that the team members "have laudable records in correctional health care" and that none have "any ties" to the UT System, the UT Medical Branch or the prison agency.

Yudof called for the study in response to continued complaints from convicts, their families and advocates for prisoners about inadequate and improper care. Since the Ruiz case was closed last summer, ending two decades of court supervision of Texas prisons,the level of care has declined, they say.

mward@statesman.com

10/05/03: Prison health study still on drawing board

Prison health study still on drawing board One year later, UT chancellor hopes to start scaled-back review of medical care
MORE ON THIS STORY
SICK IN SECRET
The hidden world of prison health care

'Deadly inadequacies' plague inmate wards Gaps in evaluating care let some mistakes go unnoticed.

Becoming guinea pigs to avoid poor prison care Ill inmates urge each other to join experiments.

State puts lockdown on the truth Texas laws and those who rule on them keep records of poor prison medicine out of public view.

Inmates pay price for others' inattention Medical care improves only when outsiders get involved, former prison lawyer says.

The rest of the series

________________________________________ By Mike Ward
AMERICAN-STATESMAN STAFF
Sunday, October 5, 2003

Last fall, Mark Yudof, chancellor of the University of Texas System, proposed a study of medical care in Texas prisons to see whether convicts' complaints were justified.

But nearly a year later, the study has yet to begin,

and UT officials are still developing plans for a study diminished in size and scope. Moreover, the study is not likely to be as independent of the University of Texas Medical Branch in Galveston as officials once pledged.

Yudof, who promised the study amid criticism of the prison health care network operated by UT's medical branch, acknowledged this week: "This is just about the most frustrating thing I've ever done as chancellor."

Yudof and Dr. James Guckian, interim vice chancellor over UT's medical schools, said they expect the study will begin soon. They said it will be conducted by the Texas Medical Foundation, an Austin-based group that conducts quality-of-care and other medical reviews for government agencies, hospitals and other health care providers.

Phil Dunne, the foundation's chief executive officer, appeared unaware Wednesday that the study might be about to begin. He said the foundation was still awaiting a response to a proposal it provided UT Medical Branch officials more than a month ago.

Dunne said the study that the foundation suggested "is not equal to what I saw Chancellor Yudof propose. . . . This is like a really small, specifically focused thing."

Nonetheless, Yudof said he still has "high hopes" the oft-delayed study will accomplish the goal he set.

"This was a hot potato because there was so much public attention on it," he said of the delays.

History of obstacles

The succession of starts and stops began Oct. 12 when Yudof, just weeks into his job as chancellor, announced plans for an independent evaluation of UT Medical Branch's prison health care system. UT's medical branch provides health care to roughly 80 percent of the 148,000 inmates in Texas prisons. (Texas Tech cares for the rest.)

In December 2001, the American-Statesman detailed continuing problems and issues with medical care in Texas prisons. For months, convicts, their families and advocacy groups had complained of inadequate and improper care ranging from lack of treatment for cancer to mistakes in record keeping and diagnoses.

The inmates' families and advocates increased their calls for reform during summer 2002, when the federal court ended its monitoring of conditions in Texas prisons. They worried the quality of care was declining. Yudof decided that a study should be done and that a three-member panel selected by Texas Health Commissioner Eduardo Sanchez should do the work. He said that the panel should include no more than two doctors and that none of its members should have ties to UT or UT's medical branch.

The study was to have included a review of inmates' medical case files, on-site inspections of prison clinics and a review of the methods and systems that other states use to ensure that prison health care is adequate and proper. "We need to have people who are independent look at it," Yudof said at the time. "We need to know if we have the right oversight system."

He pledged that the final report would be made public and would include "recommendations regarding any deficiencies" and "recommendations regarding future and ongoing assessments of quality care." Yudof also wanted the study finished by the end of 2002.

Within days of Yudof's announcement, problems arose. Prison reform and government watchdog groups assailed UT officials for involving themselves in the process of selecting the panelists, charging the study's independence was being compromised.

Then, a month later, the American-Statesman disclosed that two of the seven doctors recommended as panelists had had their medical licenses revoked or suspended for sexual misconduct, and another had been cited for negligent care. The other four candidates all were graduates of UT medical schools or had ties to Texas prison officials or the UT System. When they learned of the problems with the candidates, UT System officials immediately dropped all but one candidate from the list and agreed to start over.

In late January, the Health Department's Sanchez bowed out, insisting that his agency was not the proper one to oversee such a study. Yudof began again.

"We then asked UTMB to contact the Correctional Managed Health Care Committee and have them contract directly with TMF (the medical foundation) -- so we wouldn't have UTMB involved," he said. The committee -- made up of representatives from UT Medical Branch and Texas Tech, plus other appointees -- contracts with the UT school and Texas Tech for prison health care and oversees their work.

Negotiations went on for about two months, Guckian said, "and then we began to realize what was happening to us in the legislative appropriations process -- and we had to focus our resources on that."

By the time the Legislature adjourned in May, Yudof said, the Correctional Managed Health Care Committee had decided to opt out as well.

"They told us the study was not needed because they had just finished a study of their own, and they were satisfied with the quality of care," Yudof said.

It was back to UT Medical Branch.

"We decided to do the contract under their auspices, and Ben Raimer was given the authority to develop a contract with the Texas Medical Foundation," Guckian said.

Raimer heads UT Medical Branch's prison health care program and leads the Correctional Managed Health Care Committee.

Still more hurdles

Yudof and Guckian said contract negotiations have since been under way, with these hurdles: a new federal law governing confidentiality of medical records, various legal issues and the growing cost of completing the study Yudof first envisioned.

"It became very clear that that the cost would be prohibitive, . . . so we went back to TMF and said, 'What can we do for available funds?' " Guckian said.

UT officials originally expected to spend $30,000 to $40,000, but they learned it would cost much more to do all the work Yudof originally wanted. Yudof said the scaled-back study will now cost about $70,000 -- including an administrative review of the systems of care and a review of some medical records, probably just a few hundred of those prisoners with prevalent diseases and infections such as HIV, hypertension, hepatitis C, heart disease and diabetes.

Guckian said nurses will do much of the review work, although doctors may be involved in some parts.

And will those reviewers still have no ties to UT or UT Medical Branch? Yudof and Guckian said they want those involved in the study to be as far removed as possible, but there may be no way to eliminate everyone with UT ties since a Texas group will conduct the study.

"We'll try to eliminate people with obvious conflicts," Guckian said. Dunne said the medical foundation will comply with whatever stipulations UT includes in the contract, such as barring reviewers with ties to UT or the medical branch. Other stipulations could govern whether the public has access to any or all of the report. It's unclear what the stipulations will be because the contract isn't ready. Typically, medical confidentiality laws prohibit the release of any patient-identifying information, and most quality-of-care studies are conducted under peer review rules that also require confidentiality.

Dunne said that once UT Medical Branch signs a contract with the foundation, a study could be completed in 120 to 180 days.

Guckian said he expects a contract will be signed within a few days so the study can finally begin -- and be completed by the end of the year.

Yudof was more cautious. "Considering what's happened . . . I wouldn't bet the ranch on it," Yudof said.